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Introduction: In light of significant declines over 15 years in work-related back injuries from overexertion and more modest declines in acute traumatic injuries among a large cohort of union carpenters, we explored healthcare utilization for back problems through their private insurance coverage during the same time period. Methods: Data from workers' compensation (WC) records were linked on an individual basis with records of health care utilization through the union healthcare trust for a dynamic cohort of 18,768 carpenters from 1989-2003. Yearly utilization rates for back disorders, based on months of insurance eligibility, were calculated over the 15 years and compared to patterns of workers' compensation back injuries. Rates of private healthcare utilization were also calculated before and after a work injury adjusting for age and gender. Results: Sixty percent of the cohort did not seek medical care for back disorders through either WC or their healthcare trust; 10% sought care in both systems. WC claims for overexertion injuries were 62% lower in 2003 than in 1989 while healthcare utilization through the trust for back disorders increased 108%. Private healthcare utilization rates increased among carpenters with more WC injuries (1.3 for one work injury, 1.6 for two, 1.7 for three, 2.2 for four). Utilization patterns through the trust were slightly different for individuals following an acute traumatic work-related injury compared to those with overexertion injuries. Discussion: The patterns observed raise concern that some work-related care for back disorders could have shifted to the carpenters' healthcare trust, particularly in later years. In any event, the analyses demonstrate interplay across the two healthcare delivery systems in this working population with insurance coverage. Even with the robust data available, these issues are difficult to clearly understand.